Prognostic factors and benefits of adjuvant therapy for ampullary cancer following pancreatoduodenectomy: A systematic review and meta-analysis

Ampullary cancer is a relatively rare gastrointestinal malignancy. The purpose of this study was to evaluate prognostic factors for survival and assess the benefits of adjuvant therapy following pancreaticoduodenectomy for this entity. Medline and EMBASE databases were searched to identify eligible studies from January 2000 to August 2019. Review Manager 5.3 statistical software was used for meta-analysis. 71 studies met the inclusion criteria and were included in the analysis for a total of 8280 patients. The median (range) 5-year overall survival and disease-free survival rates were 58% (32–82%) and 51% (28–73%) respectively. In meta-analysis, age >65 years at diagnosis, tumor size >20 mm, poor differentiation, pancreaticobiliary histotype, pT3-4 stage disease, presence of metastatic lymph node, number of metastatic nodes, perineural invasion, lymphovascular invasion, vascular invasion, pancreatic invasion, and positive surgical margins were independently associated with worse overall survival, whereas adjuvant therapy was associated with improved overall survival. In summary, in patients with ampullary cancer undergoing pancreaticoduodenectomy, tumor factors are the main predictors of worse survival and adjuvant treatment confers a survival benefit.     

胰十二指肠切除术后胰瘘的影响因素研究进展

胰十二指肠切除术(Pancreaticoduodenectomy,PD)是治疗壶腹周围恶性肿瘤、癌前病变和部分良性疾病的标准术式。PD手术切除范围广,吻合口多,手术并发症较多。近年来,PD手术死亡率已经由最初的大于50%下降到目前的小于5%,手术并发症发生率也显著下降。PD术后主要并发症有胰瘘、出血、腹腔感染、胆瘘、乳糜瘘、术后胃排空障碍等。其中,胰瘘是导致PD术后早期死亡的主要原因。本文就影响PD术后胰瘘的全身因素、局部因素和手术相关因素进行综述,为降低PD术后胰瘘发生率提供临床可操作性。     

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes

BackgroundDespite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV).MethodsSince March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics.ResultsMean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004).ConclusionsRPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.     

Amylase level after pancreaticoduodenectomy in predicting postoperative pancreatic fistula

BackgroundIt is new clinical interest higher serum amylase level with pancreatitis after pancreaticoduodenectomy (PD) correlates with postoperative pancreatic fistula (POPF). Nevertheless, its evidence and study were scarce. We aimed to investigate correlation of serum amylase level immediate after PD and POPF occurrence.MethodsOf 163 patients who underwent PD at between January 2009 and December 2019, retrospective analysis was conducted to identify risk factors including serum amylase level immediate after PD for POPF occurrence.ResultsOverall incidence of POPF (25/163) was 15.3%. The patients occurred a POPF had significantly higher level of serum amylase on POD0 compared to in whom without a POPF (414 vs 253, p < 0.001). In univariate analysis, ASA classification, post pancreatectomy acute pancreatitis (POAP, serum amylase on POD0 >285IU/L) and Fistula Risk Grade were correlated with POPF occurrence. In multivariable analysis, Fistula risk grade and POAP were significantly associated with developing POPF.ConclusionIn patients with higher serum amylase (>285IU/L) on POD0 with higher fistula risk grade, comprehensive management to achieve mitigation of POPF is important.     

The effect of antecolic versus retrocolic reconstruction on delayed gastric emptying after classic non–pylorus-preserving pancreaticoduodenectomy

Background

Delayed gastric emptying (DGE) after pancreaticoduodenectomy increases length of hospital stay and costs, and may be influenced by surgical techniques.

Methods

We retrospectively compared 400 patients with antecolic gastrojejunostomy with 400 patients with retrocolic gastrojejunostomy for the occurrence of DGE.

Results

The prevalence of DGE was 15% in the antecolic group and 21% in the retrocolic group (P = .021), and median length of stay was shorter for the former (8 vs 10 days, P = .001). The difference was statistically significant with grade A DGE (9% vs 14%, P = .038), but not B or C. In a multivariate analysis, DGE was influenced by retrocolic reconstruction, as well as older age, chronic pancreatitis, preoperative bilirubin level, a history of previous upper abdominal surgery, and postoperative pancreatic fistula.

Conclusions

An antecolic gastrojejunostomy for classic non–pylorus-preserving pancreaticoduodenectomy is associated with a lower incidence of mild DGE (grade A) and a shorter length of stay.     

Effects of preoperative long-term glycemic control on operative outcomes following pancreaticoduodenectomy

Background

Diabetes mellitus is postulated to be both a risk factor and manifestation of pancreatic adenocarcinoma. This study evaluated the effects of preoperative glycemic control as determined by hemoglobin A1c (HbA1c) on outcomes following pancreaticoduodenectomy (PD).

Methods

A prospective cohort study whereby HbA1c was assessed preoperatively in 243 patients undergoing PD was performed. The primary outcome measure was operative morbidity. Secondary outcomes included individual adverse events, time to dietary resumption, and length of stay.

Results

Preoperative HbA1c ranged from 4.0% to 13.5%. Overall morbidity and incidence of specific adverse events were similar regardless of preoperative HbA1c. No correlation between HbA1c and length of stay, dietary resumption, or readmission was observed. Pancreatic fistula formation had a decreased incidence in patients with elevated versus normal HbA1c (2.2% vs 9.6%, P = .083).

Conclusions

PD can be safely performed in patients with HbA1c levels suggestive of poor long-term preoperative glycemic control. Medical efforts to optimize HbA1c should not delay resection.     

Pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials

Background

The best reconstruction method for the pancreatic remnant after pancreaticoduodenectomy remains debatable. We aimed to investigate the perioperative outcomes of 2 popular reconstruction methods: pancreaticogastrostomy and pancreaticojejunostomy.

Data Sources

Randomized controlled trials comparing pancreaticogastrostomy versus pancreaticojejunostomy were identified from literature databases (MEDLINE/PubMed, EMBASE, Web of Science, Cochrane Library).The meta-analysis included 8 studies: 607 patients who underwent pancreaticogastrostomy and 604 who underwent pancreaticojejunostomy. Postoperative pancreatic fistula and intra-abdominal fluid collection rates were significantly lower after pancreaticogastrostomy compared with pancreaticojejunostomy. No statistically significant differences were found in the incidence of delayed gastric emptying, biliary fistula, hemorrhage, reoperation, wound infection, overall morbidity, mortality, and length of hospital stay.

Conclusions

Our meta-analysis suggests that pancreaticogastrostomy not only reduces the rate of postoperative pancreatic fistula but also decreases its severity. Pancreaticogastrostomy is associated with a lower rate of intra-abdominal fluid collection. Our results suggest that pancreaticogastrostomy should be the preferred reconstruction method.     

胰头十二指肠切除术联合替吉奥治疗胰腺癌的临床观察

目的：探讨胰头十二指肠切除术联合替吉奥治疗胰腺癌的疗效。方法：2008年2月—2011年6月间,58例I~II期胰腺癌患者行胰头十二指肠切除术后分别采取替吉奥（32例,观察组）和吉西他滨（26例,对照组）辅助化疗,比较两组患者的近、远期疗效及化疗期间不良反应的发生情况。结果：两组患者化疗后血清中各肿瘤标志物水平均明显较化疗前下降（均P<0.05）,但两组间差异无统计学意义（均P>0.05）;观察组患者总有效率明显高于对照组患者（37.50% vs. 30.77%,P<0.05）;生存分析显示,观察组患者1、1.5、2年的总生存率明显高于对照组患者（均P<0.05）;两组患者化疗期间不良反应均为I、II度,两组间不良反应发生率差异无统计学意义（P>0.05）。结论：胰头十二指肠切除术加术后替吉奥辅助化疗治疗胰腺癌疗效确切,可有效延长患者术后生存期,且不良反应较轻,患者耐受良好。